Pre-Employment

Packet A – 2 (Service Representative - Driver)

Please provide clear copies of the following items:

*Commercial Driver’s License (Front/Back)

*Current DOT Medical Certificate

*TWIC Card

*Site Specific Entry Cards

*Resume (Optional)

You must also apply on our Career Center online

DRIVER'S APPLICATION FOR EMPLOYMENT

Applicant Name Date of Application

Company

Address

City State Zip

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to: · Review information provided by previous employers;· Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected

information to the prospective employer; and· Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the

accuracy of the information.Signature Date

FOR COMPANY USE

PROCESS RECORD APPLICANT HIRED REJECTED

DATE EMPLOYED POINT EMPLOYED

DEPARTMENT CLASSIFICATION

(IF REJECTED, SUMMARY REPORT OF REASON SHOULD BE PLACED IN FILE)

SIGNATURE OF INTERVIEWING OFFICER

TERMINATION OF EMPLOYMENT

DATE TERMINATED DEPARTMENT RELEASED FROM

DISMISSED VOLUNTARILY QUIT OTHER

TERMINATION REPORT PLACED IN FILE SUPERVISOR

O'Rourke Petroleum223 McCarty StreetHouston TX 77029

APPLICANT TO COMPLETE

(Answer all questions – please print)

Position(s) Applied for

Name Social Security No. Last First Middle Email Address

List your addresses of residency for the past 3 years. Current Address

Street City Phone How Long? State Zip Code Yr/Mo

Previous How Long?

Addresses Street City State & Zip Code Yr/Mo

How Long?

Street City State & Zip Code Yr/Mo

How Long?

Street City State & Zip Code Yr/Mo

Do you have the legal right to work in the United States?

Date of Birth Can you provide proof of age?

(Required for Commercial Drivers)

Have you worked for this company before? Where?

Dates: From To Rate of Pay Position

Reason for leaving

Are you now employed? If not, how long since leaving last employment?

Who referred you? Rate of pay expected

Have you ever been bonded? Name of bonding company

(Answer only if a job requirement)

Have you ever been convicted of a felony?

If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment – all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

EMPLOYMENT HISTORY (continued)

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

EMPLOYER DATE

NAME FROM MO

YR

TO MO

YR

ADDRESS POSITION HELD

CITY STATE ZIP SALARY/WAGE

CONTACT PERSON PHONE NUMBER REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED? ☐ YES ☐ NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF CFR PART 40? ☐ YES ☐ NO

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. † The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES NATURE OF ACCIDENT

(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES HAZARDOUS

MATERIAL SPILL LAST ACCIDENT

NEXT PREVIOUS NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS – DRIVER

List all driver licenses or permits held in the past 3 years

DRIVER LICENSES

STATE LICENSE NO. TYPE EXPIRATION DATE

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YES NO

B. Has any license, permit, or privilege ever been suspended or revoked? YES NO

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

DRIVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT DATES APPROX. NO. OF MILES

(TOTAL) FROM(M/Y) TO(M/Y) STRAIGHT TRUCK ☐ YES ☐ NO (VAN, TANK, FLAT, DUMP, REFER)

TRACTOR AND SEMI-TRAILER ☐ YES ☐ NO (VAN, TANK, FLAT, DUMP, REFER)

TRACTOR – TWO TRAILERS ☐ YES ☐ NO (VAN, TANK, FLAT, DUMP, REFER)

TRACTOR – THREE TRAILERS ☐ YES ☐ NO (VAN, TANK, FLAT, DUMP, REFER)

MOTORCOACH – SCHOOL BUS ☐ YES ☐ NO More than 16 passengers

MOTORCOACH – SCHOOL BUS ☐ YES ☐ NO More than 8 passengers

OTHER

LIST STATES OPERATED IN FOR THE LAST FIVE YEARS

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS – OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 9 10 11 12 COLLEGE: 1 2 3 4

LAST SCHOOL ATTENDED (NAME) (CITY, STATE)

TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature: Date:

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Reform Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.25, and 391.25 of the Federal Motor Carrier Safety Regulations.

Applicant’s Signature Date

Print Name Social Security Number

Pre-Employment Acknowledgement Form I HEREBY ACKNOWLEDGE that I have been informed by the Company of the requirement to submit to a pre-employment drug and/or alcohol test, as required by the U.S. Department of Transportation (DOT) regulations and Company policy. I understand that the DOT regulations require all prospective employees for safety-sensitive positions submit to a drug and/or alcohol test. A urine specimen will be collected at a site selected by the company and tested for drugs at a HHS/SAMHSA-certified laboratory. The laboratory results of the drug test will be reviewed, reported, and maintained by the Medical Review Officer (MRO) selected by the company. If the drug test result is negative, the MRO will report the test result to the company. I will be given an opportunity to discuss a positive laboratory test result with the MRO before the drug test is reported to the company as a verified positive. I understand that if my drug and/or alcohol test is verified/confirmed as positive, if it is determined that there has been any interference with the collection or testing process (including adulteration and/or switching specimens) or if I refuse to submit to the required pre-employment drug and/or alcohol test, I will be considered unqualified for employment in a safety-sensitive position by the Company. I also understand that, if hired, I will be required to submit to additional drug and/or alcohol tests as required by DOT regulations and as outlined in the Company policy and supportive material. I acknowledge that the Company's offer of employment is conditioned on a negative test result and I will not be allowed to perform safety-sensitive functions unless and until I pass the required pre-employment drug and/or alcohol test.

If you have any questions, please discuss them with the Company before signing. Applicant Signature: Date: Applicant Printed Name:

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with ____________________ (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize ____________________ (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Date: Signature

Name (Please Print)

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

LAST UPDATED 12/22/2015

O'Rourke Petroleum

O'Rourke Petroleum

Motor Vehicle Driver's

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing or rated at 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing or rated at 10,001 pounds or more, can transport more than 15 people (or more than 8 people when there is direct compensation), or transports hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with, including the following:

1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:

Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation, or disqualification of your driver's license or driving privilege. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to your employing motor carrier. The notification must be in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial

driver's license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I possess:

Driver’s License No. State Exp. Date

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Driver’s Name (Printed):

Driver’s Signature: Date:

Notes:

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))

Prospective Employee Name: ID Number: (print)

The prospective employee is required by Sec. 40.25(j) to respond to the following questions. 1) Have you tested positive, or refused to test, on any pre-employment drug or

alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Check one: ☐ Yes ☐ No 2) If you answered yes, can you provide/obtain proof that you’ve successfully

completed the DOT return-to-duty requirements? Check one: ☐ Yes ☐ No

I certify that the information provided on this document is true and correct.

Prospective Employee Signature: Date:

Witnessed By: Date: (signature)

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Motor Vehicle Driver's

CERTIFICATION of VIOLATIONS

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months. (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information here.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify. (Section 391.27).

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. IN NONE STATE NONE

Date Offense Location Type of Vehicle

Operated

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Driver’s Name (Print) Social Security No.

Driver’s License No. State Expirations Date

(DATE OF CERTIFICATION) (DRIVER’S SIGNATURE)

(MOTOR CARRIER’S NAME) (MOTOR CARRIER’S ADDRESS)

(REVIEWED BY: SIGNATURE) (TITLE)

O'Rourke Petroleum 223 McCarty Street, Houston, TX 77029